VAWC Form #3 CTRL NO.

_____
Republic of the Philippines
Province of Cebu
MUNICIPALITY OF _________________
Barangay ____________________

APPLICATION FOR BARANGAY PROTECTION ORDER

Name of Applicant: ________________________________________ Age: _________________________

Address: ________________________________________ Tel. # _________________________
Relationship to Victim: ________________________________________ Occupation: _________________________

Name of Victim/s: ________________________________________ Date of Birth: _________________________

Address: ________________________________________ Tel. # _________________________

Civil Status: Single Married Widow Separated Legally Separated

Occupation/
Source of Income: _________________________________________________________________________________________

Name of Children: Date of Birth: Sex:

____________________________ _______________________ _____
____________________________ _______________________ _____
____________________________ _______________________ _____
____________________________ _______________________ _____

Other Children under her care

Name Date of Birth Sex
____________________________ _______________________ _____
____________________________ _______________________ _____
____________________________ _______________________ _____
____________________________ _______________________ _____

Name of Applicant: ________________________________________ Age: _________________________

Occupation/
Source of Income: _________________________________________________________________________________________
Address: ________________________________________ Tel. # _________________________

Civil Status: Single Married Widow Separated Legally Separated

Relationship of complainant to respondent

Wife Former Wife Common Law/Live-in relationship

Dating Relationship Sexual Relationship

Acts Complained of: (pls. check)

Threats Physical injuries

Date of commission offense: _______________________________________

Place where the offense was committed: _______________________________________
If the applicant is not the victim, state the circumstance of refusal to give consent of the victim.

_________________________________________
Signature of Applicant Over Printed Name

_________________________________________
Date

VERIFICATION OF PUNONG BARANGAY

I certify that the application for BPO who personally appeared before me is a bonafide resident of this barangay and is the same
person who supplied all the above information and attest to the correctness of said information.

_________________________________________
Punong Barangay

Date Issued: ______________________________

VAWC Form #4 CTRL NO._____
BARANGAY PROTECTION ORDER

Name of Respondent: __________________________________

Address: __________________________________

ORDER

_______________________________ applied for a BPO on _________________________________, under oath stating that:

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

After having heard the application and the witnesses and evidence, the undersigned hereby issues this BPO ordering you to
immediately cease and desist from causing or threatening to cause physical harm to ___________________________________ and/or her
child/children namely:

_________________________________________ ________________________________________
_________________________________________ ________________________________________
_________________________________________ ________________________________________

This BPO is effective for 15 days from receipt.

Violation of this order is punishable by law

_________________________________
Punong Barangay
Signature over printed name

Date Issued: _______________________

Copy received by: ______________________________

Signature over printed name

Date received: ______________________________

Served by: ______________________________

Signature over printed name

ATTESTATION
(In case the Punong Barangay is unavailable)

I hereby attest that the Punong Barangay _____________________________ was unavailable to act on Application for Barangay
Protection Order No. _______ filed by ____________________________ on ___________________________________ at
______________________ a.m./p.m. and issue order.

_________________________________
Barangay Kagawad
Signature over printed name
VAWC Form #5
Bry. Form No. ______
Control No. ______

Republic of the Philippines

Province of Cebu
CITY/MUNICIPALITY OF SAMBOAN
Barangay _______________________

VIOLENCE AGAINST WOMEN AND THEIR CHILDREN INCIDENT REPORT

I. PERSONAL CIRCUMSTANCES
(A) Name of Complainant/Victims Age Address

____________________________ __________________ _________________________________

____________________________ __________________ _________________________________
____________________________ __________________ _________________________________

(B) Civil Status (C) Relationship to Perpetrator

Married Wife Girlfriend

Separated Ex-wife Dating relationship

Widow

(D) Occupation/Profession: Complainant Perpetrator

___________________________ __________________________

II. INCIDENT DETAILS

(A) Date/s of Violence Committed ______________________________________

(B) Date Reported _______________________________

Physical _________________________________________________________________________________
Sexual _________________________________________________________________________________
Psychological _________________________________________________________________________________
Economic Abuse _________________________________________________________________________________

III. ASSISTANCE EXTENDED/PROVIDED TO VICTIMS

Specific Service Provided Provided by: Remarks

Medical __________________________ _____________________ _________________

Counseling __________________________ _____________________ _________________

Referral to __________________________ _____________________ _________________

Shelter __________________________ _____________________ _________________

Issued BPO __________________________ _____________________ _________________

Prepared by:

_________________________________ _________________________________
(Date Accomplished) (Signature Over Printed Name)
OFFICIAL ACCOMPLISHING THIS FORM

Note: Please bring copy of this form to referred agency.